Would you like to leave bedside nursing? Join our UR-101 program for RNs and LPNs today. Work from home for major insurance companies.

Utilization Review for RN, LPN, and LVNs

Remote Nursing Course by Marie Peppers, LPN, and Judy Clarke, RN

Like many nurses, you may be unfamiliar with the nurse’s role in Utilization Review (UR). Although the UR concept isn’t new, the nature of the role and demands on utilization reviewers have changed dramatically over the years. For some bedside nurses, their first exposure to UR comes when a UR nurse takes them aside to ask about the status or condition of a patient in their care. UR nurses can be found in the hospital, surgery centers, urgent care, doctor’s offices, insurance companies, and insurance company vendors. Most remote positions are found with insurance companies and insurance company vendors. Most acute and subacute facilities require utilization reviews to be performed on-site. Generally, remote UR positions are full-time, benefited positions, or full-time contract positions.

There are three types of utilization review positions: preauthorization, concurrent, and retroactive.

A pre-authorization review requires the nurse to determine if a requested service/ medication by a provider is medically necessary for a patient to have. A nurse uses evidence-based clinical guidelines compared to medical documentation to decide the case. Nurses are often required to call the requesting provider for more information or send the case to a medical reviewer for final determination. Concurrent reviews are conducted primarily in inpatient settings to determine continued coverages/services to be provided for a patient. Concurrent review nurses also work as part of a multi-disciplined team to determine step-down care, transition of care, outpatient services, and discharge planning. Retroactive reviews are conducted after a service/medication has been completed. Like preauthorization reviews, except for timing, retroactive reviews are commonly completed after emergent care has been provided.

Join our course here:?Work at your own pace from home .

The remote utilization review nurse needs a solid knowledge base, high-level critical thinking skills, and the ability to apply evidence-based guidelines to be successful. Utilization review is fast-paced and metric (number) driven; your performance is based on making medical determinations in the best interest of the patient and the organization in a timely manner.

By helping to prevent overuse or misuse of medical resources, UR nurses promote high-quality care and cost containment. An interprofessional approach and clear, concise communication are essential for ensuring authorization of services that are planned or being rendered, as well as for maximizing reimbursement and minimizing costs. By applying evidence-based criteria and critically evaluating patient-care practices, UR nurses can influence resource-use management.

RNs, LPNs, LVNs, this program is for you.

Job placement assistance, resume assistance, remote lessons on the "Teachable" platform.

1-year access to all materials. Private Facebook group for Job postings and support.

Would you like to leave bedside nursing? Join our UR-101 program for RNs and LPNs today. Work from home for major insurance companies.

Join us today and meet the nurses and teachers in your course. Lots of interaction and friendships to be made.

You can also join our Facebook group of 21,000 nurses interested in alternative careers in nursing.